Peripheral and bone marrow hemophagocytosis in dengue fever

摘要

An eight-month-old Indonesian boy with glucose-6-phosphate dehydrogenase (G6PD) deficiency was admittedto our hospital for suspected leukemia. He was firstadmitted to a local hospital a week ago suffering from feverof unknown source, and he had normal complete bloodcount (CBC) with a hemoglobin level of 11.9 g/dL. He wastreated with multiple antibiotics (amoxicillin, cefotaxime,and meropenem) and antipyretics (intravenous, oral, andsuppository paracetamol and metamizole) from day 1 withno improvement. CBC on day 6 showed a hemoglobin levelof 8.7 g/dL (normal, 10e14), white blood cell (WBC) countof 46.0 109/L (normal, 6e17.5), and platelet count of90 109/L (normal, 140e460), with immature cells reportedon a blood smear. When he arrived at our hospitalthe next day, he was found to be pale and jaundiced andhad a palpable liver edge and splenic tip. No rash wasobserved. CBC showed a hemoglobin level of 7.6 g/dL, WBCcount of 63.5 109/L, platelet count of 207 109/L. Hehad a bilirubin level of 35 mmol/L (normal, 0e26), ALT of 85U/L (normal, 3e40), and AST of 132 U/L (normal, 0e40).Peripheral blood smear revealed leukoerythroblastosis,occasional blasts, hemi-ghost red cells, and hemophagocytosis(Fig. 1A). Further, bone marrow aspiration showedhemophagocytosis (Fig. 1B) with a background of normalhemopoiesis. Serological tests were positive for dengue IgMand NS1 antigen. The diagnosis of dengue fever was made Figure 1 A. Photomicrograph of peripheral blood smear( 100; Wright’s) showing leukophagocytosis by a monocyte(black arrow) and a hemi-ghost red cell (red arrow), a characteristicfinding in hemolysis associated with glucose-6-phosphate dehydrogenase deficiency. B. Photomicrograph ofthe bone marrow aspirate ( 100; Giemsa’s) showing multilineagehemophagocytosis (black arrow).